COVID-19 Vaccination Coverage and Demographic Characteristics of Infants and Children Aged 6 Months–4 Years — United States, June 20–December 31, 2022

Although severe COVID-19 illness and hospitalization are more common among older adults, children can also be affected (1). More than 3 million cases of COVID-19 had been reported among infants and children aged <5 years (children) as of December 2, 2022 (2). One in four children hospitalized with COVID-19 required intensive care; 21.2% of cases of COVID-19-related multisystem inflammatory syndrome in children (MIS-C) occurred among children aged 1-4 years, and 3.2% of MIS-C cases occurred among infants aged <1 year (1,3). On June 17, 2022, the Food and Drug Administration issued an Emergency Use Authorization (EUA) of the Moderna COVID-19 vaccine for children aged 6 months-5 years and the Pfizer-BioNTech COVID-19 vaccine for children aged 6 months-4 years. To assess COVID-19 vaccination coverage among children aged 6 months-4 years in the United States, coverage with ≥1 dose* and completion of the 2-dose or 3-dose primary vaccination series† were assessed using vaccine administration data for the 50 U.S. states and District of Columbia submitted from June 20 (after COVID-19 vaccine was first authorized for this age group) through December 31, 2022. As of December 31, 2022, ≥1-dose COVID-19 vaccination coverage among children aged 6 months-4 years was 10.1% and was 5.1% for series completion. Coverage with ≥1 dose varied by jurisdiction (range = 2.1% [Mississippi] to 36.1% [District of Columbia]) as did coverage with a completed series (range = 0.7% [Mississippi] to 21.4% [District of Columbia]), respectively. By age group, 9.7 % of children aged 6-23 months and 10.2% of children aged 2-4 years received ≥1 dose; 4.5% of children aged 6-23 months and 5.4% of children aged 2-4 years completed the vaccination series. Among children aged 6 months-4 years, ≥1-dose COVID-19 vaccination coverage was lower in rural counties (3.4%) than in urban counties (10.5%). Among children aged 6 months-4 years who received at least the first dose, only 7.0% were non-Hispanic Black or African American (Black), and 19.9% were Hispanic or Latino (Hispanic), although these demographic groups constitute 13.9% and 25.9% of the population, respectively (4). COVID-19 vaccination coverage among children aged 6 months-4 years is substantially lower than that among older children (5). Efforts are needed to improve vaccination coverage among children aged 6 months-4 years to reduce COVID-19-associated morbidity and mortality.

Race and ethnicity data were available for 71.4% of children aged 6 months-4 years and were analyzed by the following categories: Black, Hispanic, non-Hispanic American Indian or Alaska Native, non-Hispanic Asian (Asian), non-Hispanic Native Hawaiian or other Pacific Islander, non-Hispanic White (White), and non-Hispanic multiple races or other (multiracial/other). The percentage of children aged 6 months-4 years receiving the first dose of COVID-19 vaccine was calculated by race and ethnicity.
To investigate disparities in vaccination coverage by urbanrural environment, first-dose coverage was also calculated by two-and six-level urban-rural classifications according to the 2013 National Center for Health Statistics (NCHS) urbanrural classification scheme (6). To dichotomize counties as urban versus rural, four of these six categories (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) were combined and considered urban areas, and two (micropolitan and noncore) were combined and considered as rural areas (6). Eight counties in California with <20,000 residents were excluded from the analysis because of data-sharing restrictions on county-level information reported to CDC. All analyses were conducted using SAS software (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. ¶ ¶ As of December 31, 2022, a total of 1,755,596 (10.1%) children aged 6 months-4 years had received ≥1 dose of a COVID-19 vaccine (Table), and approximately 39% of these children received the first dose within 1 month of vaccine authorization (Supplementary Figure, https://stacks.cdc.gov/ view/cdc/124660). Overall, 5.1% of children in this age group completed the series during the study period (Supplementary Table,  Among vaccinated children aged 6 months-4 years, race and ethnicity were known for 71.4%. Among those with known race and ethnicity who received at least the first dose, 7.0% were Black, and 19.9% were Hispanic, whereas these groups account for 13.9% and 25.9%, respectively, of the U.S. population of children aged 6 months-4 years. In contrast, 55.3% of vaccine recipients were White, and 13.4% were Asian children; these groups account for 48.4% and 5.7% of the U.S. population of children aged 6 months-4 years, respectively (4) (Figure 2). Race and ethnicity were unknown or not reported for 501,899 (28.6%) children, either because race and ethnicity had not been recorded (24.5%), was reported as "other" (3.6%), or was not reported (0.5%) because of jurisdictional policy or law (Vermont and eight counties in California).
COVID-19 vaccination coverage with ≥1 dose was lower among children aged 6 months-4 years residing in rural counties (3.4%) than among those residing in urban counties (10.5%), according to the two-level urban-rural classification (Table). The six-level classification indicated that coverage was highest (12.5%) among children residing in large metro areas and declined as areas became more rural, with the lowest coverage (2.7%) among children residing in noncore (i.e., most rural) areas. Overall, coverage in 41 jurisdictions was higher in urban counties, in two jurisdictions (Arizona and Wyoming) was higher in rural counties, and in four jurisdictions (Louisiana, Michigan, Mississippi, and Nevada) coverage was similar (i.e., within two percentage points) in urban and rural counties. Coverage comparisons could not be made for four jurisdictions (Delaware, District of Columbia, New Jersey, and Rhode Island) that have only urban counties.

Discussion
Even after 5 months since COVID-19 vaccines were authorized for children aged 6 months-4 years, coverage with ≥1 dose among this age group substantially lags behind that in older children. Two months after vaccine was approved for children aged 5-11 years and 12-15 years, coverage was 24.0% and 33.3%, respectively, in these age groups (5). The low coverage to date in children aged 6 months-4 years is concerning and might indicate challenges to future vaccination coverage, especially given that bivalent booster doses are now authorized for this pediatric population as well. † † † Disparities in COVID-19 vaccination coverage that have emerged in the COVID-19 vaccine rollout (5) are evident among children aged 6 months-4 years. The lower coverage observed among children residing in rural counties than among those in urban counties is consistent with results from a recent  † Persons with state of residence reported as "unknown" (1,258) were not included in jurisdiction-specific counts. § Persons with sex reported as "unknown" (7,215) were not included in male and female counts. ¶ Persons with age reported as zero years at time of vaccination were assumed to be aged ≥6 months. ** Information on the resident's county of residence was not known or was invalid for 88,243 (5.0%) persons.
survey which found that 53% of parents of children in rural areas reported that they will "probably or definitely not get their child vaccinated" with COVID-19 vaccines compared with 38% of parents in suburban areas (7). However, in Arizona and Wyoming, coverage was higher in rural counties than in urban counties; the reasons for this are not well understood and merit further investigation. Asian and White children were overrepresented among those vaccinated, whereas Black and Hispanic children were underrepresented. Several factors might contribute to these disparities. Black and Hispanic communities have high rates of poverty (19.5% and 17.0% respectively), compared with White communities (8.2%), which might affect parents' or caregivers' access to vaccination locations, ability to leave work for or travel to vaccination appointments, or access to primary care providers for pediatric vaccination advice (8). In a 2022 Kaiser Family Foundation survey published in July 2022, 47% of parents of children aged 6 months-4 years with household incomes ≥$90,000 reported talking to their pediatrician about a COVID-19 vaccine, compared with only 18% of parents with a household income of $40,000-$90,000 and 28% of parents with a household income of <$40,000 (9). In addition, approximately 40% of Hispanic parents reported that they could not get the vaccine from a place they trust, and approximately one third were concerned about having to pay out-of-pocket for their child to get the vaccine compared with only 13% of White parents (9). Approximately 40% of Black parents in that survey reported concern about having to take time off from work to take their child to get vaccinated or to take care of them if they had side effects after receiving the vaccine compared with only 18% of White parents (9). Having access to a medical home § § § and a recommendation from a trusted health care provider can help address parental concerns about COVID-19 vaccine safety and effectiveness and can help improve pediatric COVID-19 vaccination coverage (5).
Many factors contribute to vaccine hesitancy among parents of the youngest children, ranging from worries about side effects to confusion about information regarding COVID-19 vaccines from federal health agencies (9). According to the Kaiser Family Foundation COVID-19 Vaccine Monitor, parental intention to vaccinate children in this age group has remained low, with more than one half the parents of children aged 2-4 years responding in June 2021 that they will § § § https://www.aap.org/en/practice-management/medical-home/medicalhome-overview/what-is-medical-home * Race and ethnicity was available for 71.4% of persons. † The U.S. Census Bureau does not include the category "other" as a race category, although immunization information systems in many jurisdictions might report "other. " In this analysis, "other race" was considered unknown, and no comparison with U.S. Census Bureau data was made.

Summary
What is already known about this topic?
Although severe COVID-19 hospitalization and death occur more commonly among adults, young children are also affected.
What is added by this report?
As of December 31, 2022, coverage with ≥1 COVID-19 vaccine dose among young children (those aged 6 months-4 years) was 10.1%, and 5.1% had completed the primary series. Coverage among young children varied by jurisdiction, urbanicity, race, and ethnicity. Five months after the COVID-19 vaccines became available to young children, their vaccination coverage is substantially lower than that in older children.
What are the implications for public health practice?
Enhanced evidence-based practices are needed to decrease barriers to vaccination and increase parental COVID-19 vaccine confidence to improve COVID-19 vaccination coverage among young children to reduce associated morbidity and mortality.
"not vaccinate immediately" (10) and more than one half of the parents reporting that they will "definitely not" get their children aged 6 months-4 years vaccinated in September 2022. ¶ ¶ ¶ Among parents of unvaccinated children aged 6 months-4 years, approximately 80% were concerned about side effects from the vaccine, and 70% were somewhat or very concerned that the vaccine would not keep their child from getting sick (9). The findings in this report are subject to at least five limitations. First, children who received COVID-19 vaccines from different entities that used different methods for submitting data (e.g., if the first dose was given at a pharmacy and the second dose was given at a mass vaccination site) might not have their first and second doses linked, which could have led to underestimation of the percentage of children who completed the vaccination series. Second, if a child inadvertently received a different recipient identification number when receiving their second dose, first and second doses could not be linked. Third, race and ethnicity were unknown for approximately 30% of children aged 6 months-4 years, which could bias the findings. Fourth, the U.S. Census Bureau does not include "other" as a race category; however, many IIS jurisdictions might report race as "other," which could affect the interpretation of proportions for this category. Finally, the CDC's National Center for Health Statistics Urban-Rural Classification was developed in 2013, and counties once classified as rural in 2013 might no longer have been rural in 2022. ¶ ¶ ¶ https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccinemonitor-dashboard/; https://www.kff.org/coronavirus-covid-19/pollfinding/kff-covid-19-vaccine-monitor-september-2022/ An estimated 3 million COVID-19 cases and more than 500 associated deaths have been reported among children aged <5 years since the start of the COVID-19 pandemic (1). Children aged 6 months-4 years are now eligible for COVID-19 vaccination; public health practitioners, health care professionals, child care facility and school administrators, and state and local governments can employ evidence-based practices**** to decrease barriers to vaccination and increase confidence in COVID-19 vaccines, which can help reduce COVID-19-associated morbidity and mortality among the nation's youngest children. **** https://www.cdc.gov/vaccines/covid-19/planning/children.html Acknowledgments COVID-19 Vaccine Task Force; U.S. Department of Defense; immunization program managers, immunization information system managers, and other staff members of the immunization programs in the 64 jurisdictions and five federal entities who provided these data.